GW1-2022-03249_Well Construction - GW1_20220314

PrinfForm
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO DESCRIrn0N
2187-A ft.
NC Well Contractor Certification Number
R' J+7 R'
I5.OUTER CASING for multi-caved wellsl OR LINER(If applicable)
Hedden Brothers Well Drilling, Inc FROG! TO DTAMETER THICIL�iESs MATERIAL
Company Name
n. fG in.
p 16.INNER CASING OR TUBING eothermal 0001
2.Well Construction Permit#:&V-99-/8- 9—11a97 FRONT I TO I DIAMM11 I TMrTLVEss I MATERIAL
List all applicable ute11 construction permirs fl a.U1C.Colurty,State,variance,etc.) 0 R. I 8 It. In.
3.Well Use(check well use): 8 n. �O ft. in. 18 8 T L
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS ,.IATERIAL
fL
b'rr oMunicipal/Public ft. ft. in.
Geothermal(Henting/Cooling Supply) Residential Water Supply(single) ft, ft. in.
Industrial/Cotrlmercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EJIPL ACEdIE\TMETHOD Q A31OGAT
Non-Water Supply Well: ft. 20 ,d .„ I Dumvad
Monitoring Recovery
Injection Well: fr.
q az8c �Groundvvatcr Rcmedia
it.
Aquifer Recharge tion It. I n.
Aquifer Storage and Recovery �'}Salini Bier 19.SAND/GRAVEL PACK if a lieable)
C� ryarr FRON�1 To MATERIAL EMPLACEME\TMETHOD
Aquifer Test �StormwaterDrainage ft. I tc I
Experimental Technology Subsidence Control fr. I ft
Geothermal(Closed Loop) Tracer 20.DRILLTl\G LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM ToI DESCRIPTION'[color.hardness.Millrad nVL grain stet eta)
0 ft- I AD
IL I clay b sand
4.Date Well(s)Completed: Well ID#r Iso
ft. I n. I granite
Sa.Well Location:co
ft. n.
gts,d�t LOWac, ft. ft.
Faciliry�/�OwncrName Facility lD0(if applicable) fr. ft.
SDI 00-M P L' PJ. uhi Nier 48789 AT ft. I
Physical Address.City,Ad Zip MAR
fr. I ft.
�A ASa0 cuti V rlb d-tety-3-7 39 2L REtVL-RIGS
County Parcel Identificarion No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or Temporary Signature ofCertirrcd Well Contractor Date"f� By signing this Jorm.1 hereby certify rha! N urll(s)was(free)constructed in accordance
7.is this a repair to an existing well: n Yes or No atilt ISA NCAC 02C.0100 or/SA NCAC 03C.0200/yell Consmicilon Standards and thin a
lJthv is a repair,Jill out inourt rvrll eonstnretion inforin.don rdeeplain the w°trrrr.of the copy ofthis record has been proylded to the well otmer.
repair under#21 remarks section or on the back ofthfs farm.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only OW-1 is needed. Indicate TOTAL NUMBER of veils construction details. You may also attach additional pages if necessary.
drilled: ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1375 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For muldp/e telis list all depths kfdierent ti ratnple-3@200•aitd 1@100'1 construction to the following:
10.Static water level below top of casing: 50 (ft.) Di dslon of Water Resources,Information Processing Unit,
Ifrvater level Is above casing,use'•+,. 1617 Mall Service Center,Raleigh,NC 2 76 9 9-1 61 7
11.Borehole diameter: j2 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy;of this form within 30 days of completion of well
construction to the following:,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_142 _ A•Iethod of test: 24c.For Water Suooh•g Injection Wells; In addition to sending the form to
t the address(es) above, also'submit one copy of this form tvirhin 30 days of
13b.Disinfection hype: t'S amount: Q Q2.( completion of well construction to the county health department of the county
` where consttticted.
Form GW-I North Carolina Department of Environmental Qualiry-Division o:Watcr Rsources Rcviscd 2-2'-2016
I